Sunday, December 31, 2006

Here are the Top 25 posts for 2006, counting down from #25 to #1 (by page views, per Google Analytics). Of course, the older articles are more likely to make it to this list, as well as those which were well-linked (like #1, which has a link on Wikipedia). For what it's worth, the main blog page had 27,809 page views, with 9991 "absolute unique visitors" (I'm sure we had at least 9 more prior to installing Analytics, so I'm callin' it 10,000).

Now what does that mean?Posting from my vacation, regular blogging to resume soon. To ClinkShrink & Roy and to all our friends in the blogosphere:Wishing you a happy, healthy (physically & mentally!) New Year!

Friday, December 29, 2006

I don't know how useful this is, as I never rank the list of emailed articles I get weekly from MDLinx, so I'm not sure how many others do. That being said, here is a list of the 50 top-rated psych articles for 2006.

Wednesday, December 27, 2006

Now that Dinah's gone for a week I will take this opportunity to blog about all things corrections-related until she posts a comment begging me to stop. Oh wait, I do that anyway.

Here goes.

When I go on vacation one of the things I really enjoy is to visit historic old prisons. (Yes I know that sounds odd, but think about this---Eastern State Prison had 50,000 visitors in one year after it was turned into a museum.) There are six correctional facilities that have been designated as National Historic Landmarks. I've been to a couple and I thought I'd write about some of the others.

Located at the site of an old copper mine, Newgate Prison (originally called Simsbury Prison) was the first penitentiary in America. During the American Revolution it was used to house Tory sympathizers---the Guantanamo Bay of its time. Inmates were kept 70 feet underground, in the various nooks and crannies of the mine shaft. In spite of the fact that all the exits were sealed there were a surprising number of escapes from the prison, and it was the site of the first mass escape in American history. Fans of the show Prison Break might enjoy reading about the ingenuity of the plans laid by these early prisoners on the American Heritage web site.

George Washington used Newgate to get rid of his troublemakers, as documented in the text of one of his letters:

Gentn.: The prisoners which will be delivered you with this, having been tried by a Court Martial, and deemed to be such flagrant and attrocious villains that they cannot by any means be set at large or confined in any place near this Camp, were sentenced to be sent to Symsbury in Connecticut; you will therefore be pleased to have them secured in your Jail … so that they cannot possibly make their escape … I am, &cGeorge Washington

The Walnut Street Jail doesn't exist anymore, but its former location is marked by a plaque at the corner of Walnut and Sixth Street in Philadelphia. It was the first American jail. It was unusual because it was the first correctional facility to classify inmates according to offenses, and to house them accordingly. During Colonial times the Quakers used the jail to model a theory of rehabilitation known as the Pennsylvania System. Under this system offenders were kept in continuous solitary confinement with little chance to interact with one another. The theory was that this would automatically lead to introspection, penitence and reformation. Thus, the idea of the penitentiary was born. As harsh as this sounds, it was actually humane for its time since the Quakers---chief among them Benjamin Rush and Ben Franklin---called for the use of this method of reformation rather than the use of capital punishment for anything other than murder.

During the Revolution the jail was used by the British to house American prisoners of war in occupied Philadelphia. The Pennsylvania Prison Society has a nice history of the jail with more detail.

One other piece of historical trivia---the jail was the site of the first air flight in the United States. On January 19, 1793, a fellow by the name of Jean-Pierre Blanchard took off from the jail yard in a hydrogen balloon and later landed in New Jersey. George Washington witnessed the takeoff.

This is one of the prisons I've visited, and let me tell you it doesn't look like a place I'd mind being in if I had to be locked up! Located on the island of Maui, it was designated the Hawaii State Prison in 1852. As the whaling industry increased the rate of crime increased as well. The museum has posted a list of the crimes that inmates were convicted of, like "furious riding" (the nineteenth century equivalent of drunk driving) and "bastardy" (I'm not going to guess at that one!).

Although the cells were small and barren, the prison yard itself is fairly luxurious. It was hardly a punitive environment. The museum displays an excerpt from the diary of one prisoner, a sixteen year old sailor:

"No restrictions are placed on the use of cards or tobacco...and any sedate individual could therefore lay back all day with a pipe in his mouth and enjoy himself at a game of euchre as well as though he was comfortably stowed away in a beer house."

The prison was eventually closed when the death of the whaling industry essentially eliminated most of the local criminal activity.

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Last but not least, this curious piece of correctional trivia:

In 1924 the Governor of Pennsylvania sent his dog, Pep, to the Eastern State Penitentiary for allegedly killing his wife's cat. The "cat-murdering dog" was even given an inmate number: C2559. No word yet on any book or movie deals.

Tuesday, December 26, 2006

Two interesting new research pieces came out this past week or so on aging and dementia.

First, this piece about a gene which is found more often in folks who live 100 years, suggesting that people with the val-val variant of the CETP gene (cholesteryl ester transfer protein) may have a better shot at living a longer life. Centenarians with this genetic variant were also five times less likely to have dementia. The gene, found on Chromosome 16 (OMIM), produces a protein involved in lipid metabolism which results in larger, less sticky, cholesterol particles. The article came out in today's Neurology.

I looked in PubMed for similar articles from this author (Barzilai) and found this April 2006 article in PLoS Biology looking at several longevity-related genes in this same population. This article describes two genes which are more prevelant in really old people: the val/val (also known as I405V) variant of CETP and the -641C variant of the APOC3 gene (another one that deals with lipids).

Here's what's really cool. This guy has gathered this big group of centenarians and is doing genome-wide scans to determine which genes may be associated with longer (and healthier) lives. This work comes out of Albert Einstein's Institute for Aging Research.

The second item is the NEJM article, from Gary Small at the UCLA Center on Aging, which showed that a molecule (FDDNP) binds to the amyloid plaques and tau protein tangles which are characteristic for Alzheimer's disease. After an injection of this experimental tracer chemical, a PET scan can then show where this stuff is in the brain. If there's enough of it, and in the right places, chances are good that you have (or are developing) Alzheimer's dementia.

This is just a research tool, at the moment. Neither this imaging tool, nor the above genetic tests, can be used clinically in the assessment of dementia risk or diagnosis. Maybe one day.

Sunday, December 24, 2006

We were a week longer than we wanted to be to get this one out. We recorded this one on 12/18/06 at Dinah's studio (her kitchen), while she served us homemade cookies and hot chocolate with Kahlua.

I did a lot of homework about microphones and recording sound quality. The gold standard would be for us each to have our own mic, while simultaneously recording on three different channels. That way the volumes can be individually adjusted so we don't have such a difference in voice quality.

That would be going overboard. So I did find a USB mic that had good reviews for podcasting. It took some hunting, but I found it for $100 at a Guitar Center. Dinah thinks that *I* have gone overboard. Regardless, let us know how it sounds. On my to-do list is to put up a PayPal donation button on the podcast site, to cover bandwidth and microphone costs. (It won't go to Kahlua, I promise.)

Here are the show notes for this week's podcast. We hope you have a safe and happy holiday.

New York's Timothy's Law: since we recorded this, Governor Pataki signed the bill into law, which provides for parity insurance coverage for mental illnesses. We also discuss a newspaper editorial which links this issue to post-incarceration treatment of sexual predators. I believe the original requirement to include addictions was removed due to cost concerns raised by insurance companies. That makes no sense.

Friday, December 22, 2006

I am off shortly for a few days of 'relative' festivities (no blood to be shed) and then a week of real vacation. In case I don't post while away:

Season'sGreetingsto All!

This post is dedicated to Roy, with affection.

From the New York Times , Penelope Green writes in "Say Yes to Mess" about how clutter is good, organization over-rated. January is Get Organized Month, but we're told their's a counter movement of people fighting the Get Organized trend, people who shun Staples and The Container Store, organizing items and the pursuit of neatness.

Mess tells a story: you can learn a lot about people from their detritus,whereas neat — well, neat is a closed book. Neat has no narrative and nopersonality (as any cover of Real Simple magazine will demonstrate).

So why on our Psychiatry blog? I can't tell you how much time people spend in psychotherapy talking about how they wish they were more organized, how they have all these household chores to do, how they regret the time they spend in front of the TV or computer (blogging, no doubt), sleeping, gaming, doing other non-organizing things. It's the funny dilemma: they want things changed, but they don't want to change them. Do you realize, I never say, that in the space of this therapy session, an entire closet could be dealt with? And if it's not enough to loathe ones self for all drawers-not-organized, yet even more hours in psychotherapy are spent talking about the spouse/partner/roommate whose sense of neatness is mismatched. There's the "Can You Believe What A Slob She Is?" side and the "What a Neurotic Freak Who Can Never Be Pleased" Side. So, yes, "Say Yes To Mess" fits right in with psychiatry themes.

So I am "pretty neat." I love The Container Store. I only like planned clutter. Everything has a place, my children's doors are kept closed and I mentally write those rooms off. I stock decorative boxes and ottomans with removable tops so mess can be scooped, dumped, and lidded. Throwing things out makes me happy. Sorting is the key to the good life. With kids and a dog with a social life, neighbors with keys, and more remote controls and sports equipment than Sports Authority, it's really more idea than fact, but I am "pretty neat" but not as neat as Camel.

It’s a movement that confirms what you have known, deep down, all along:really neat people are not avatars of the good life; they are humorless andinflexible prigs, and have way too much time on their hands.

Wednesday, December 20, 2006

My confabulated friend is a dermatologist who somehow works all day in spiked heels. Her confabulated mother has a long history of depression and has needed psychiatric care for many years; the situation has been complicated by the fact that the mother now has a progressive dementia, and my dermatologist friend has to take mom to her psychiatric appointments. Because the mother is no longer a reliable observer of her own behaviors, my friend on her heels goes in for at least part of every session.

She imagines that the psychiatrist treats her a little differently because she is a physician: he discusses the mother's behaviors, diagnostic issues, medication regimens in doctor-speak and he chats with her just a bit. He is, however, both friendly and formal, and he honors with my friend all the same boundaries that he would honor with any family member of any patient. He makes a point of asking how my friend is at every session, of giving her a chance to talk about how difficult it is on so many levels to deal with her mother's decline. So the high-heeled dermatologist likes the psychiatrist and feels he is taking good care of both of them, even if she's not the identified patient.

This morning, the psychiatrist was running late. Mom had to go to the restroom, and my friend was left in the waiting room with psychiatrist's secretary: a woman who makes everything just a little more complicated then it needs to be and who has a fondness for talking. No, she didn't pull out her moles, but she did begin to talk about Dr. Shrink's life, how he was running late because he was meeting with his divorce lawyer, that he'd had a brief affair but it was all in the past and his wife was divorcing him anyway, and the custody battle for the 2 cats (placed her for Clink) was a nightmare. "But Dr. Shrink doesn't want anyone to know this so don't tell him I told you," the secretary finished. Mom returned from the bathroom, Dr. Shrink finally arrived, the appointment went without event, but my friend was uncomfortable the whole time.

She kicked off her shoes, at long last, and began to tell me about her discomfort. She realized that she'd quietly harbored the idea that Dr. Shrink led a perfect life: All Gone. She saw him as someone trustworthy and honorable, and she didn't need to know he'd had an affair. But most of all, she was angry with the secretary for imploring her not to tell. Of course there was no legal issue of confidentiality here, my friend owed the secretary nothing, but she wondered if the secretary couldn't respect her boss's privacy, would she respect her mother's? And shouldn't she tell Dr. Shrink that his secretary was blabbing about his personal life--of course she should--but did she want to feel responsible for someone being fired? And how would she continue to deal with the blabbing secretary if he didn't fire her? Would mom's medicare forms suddenly not be filed correctly? Would it be even harder to get scheduled in to see Dr. Shrink? Could the dermatologist simply knock her on the head with one of those spike heels and be done with it?

I've been plagued with a non-confabulated version of this story for the past few days. Clink? Roy? any insights?

With thanks to Victor from my Fiction Techniques class for the use of his high-heeled dermatologist. No skin off anyone's back.

Tuesday, December 19, 2006

I guess you could say that this post is a teaser for our next podcast. During our taping we (meaning "I") got on a roll about civil commitment for sex offenders. I mentioned something in passing about the history of these laws but since I had already dominated the topic for a bit on the podcast I didn't go into detail about that. I think it's important to have a background on this issue because there are still states trying to pass these laws.

Here's the background:

One of the earliest commitment laws for criminals was adopted in Minnesota in 1939. It was known as the "psychopathic personality" statute and it allowed for commitment of people who suffered from:

'...conditions of emotional instability, or impulsiveness of behavior, or lack of customary standards of good judgment, or failure to appreciate the consequences of his acts, or a combination of any such conditions, as to render such person irresponsible for his conduct with respect to sexual matters and thereby dangerous to other persons'.

The statute was promptly and unsuccessfully challenged as unconstitutionally vague and a violation of equal protection in the 1940 case Pearson v Probate. The United States Supreme Court responded: "But we have no occasion to consider such abuses here, for none have occurred." In other words: Nice try but you lose.

In 1997 the United States Supreme Court decided Kansas v Hendricks. Hendricks was an admitted pedophile who was scheduled to be released from prison. He was civilly committed under the state's Sexually Violent Predator Act which allowed for commitment of people with mental abnormalities or personality disorders who were "likely to engage in predatory acts of sexual violence". Hendricks appealed his commitment alleging that the commitment should have been based on "mental illness" rather than "mental abnormality". He also made a claim of double jeopardy---two punishments for one crime. He lost on both counts. The Supreme Court said that it would leave the states to determine their own definition of mental illness, and also said that a civil commitment was not a punishment since the purpose of confinement was beneficent (for treatment).

Within three months of the Hendricks decision the National Association of State Mental Health Program Directors adopted a position statement objecting to the decision. They did not acknowledge sexual paraphilias as a legitimate diagnosable mental illness and objected to the idea that confinement was for the purpose of treatment. Clearly, sex offenders were not welcome in hospitals.

The followup to Hendricks came in the 2002 case Kansas v Crane. Crane was a committed exhibitionist who challenged his confinement because the judge at his commitment hearing did not make any finding about him being unable to control his dangerous behavior. Traditional commitment laws require that the patient be both mentally ill and dangerous. The Sexually Violent Predator Act required that the dangerousness be based on a "difficulty or inability to control" the dangerous behavior. The Kansas Supreme Court overturned his commitment because the trial judge never said Crane was unable to control his behavior. The US Supreme Court found that this interpretation of the statute was overly strict---that it was enough just to show the patient had difficulty or impairment in his behavioral control. Bottom line: courts now had to prove a volitional element during the civil commitment hearings in addition to proving that a mental abnormality existed.

Rapidly coming up to date (and to keep this post shorter), we now have 17 states with commitment statutes. There is considerable variation in the construction of the laws with regard to who makes the release decision and the standard of proof for commitment. The consistent experience with these laws is that hundreds of people have been confined over the past ten years but only a handful have been released. Committed sex offenders are requiring more of each state's budget. Costs for treating sex offenders range from $30,000 to $125,000 per inmate per year, and more is being requested.

The problems with sex offender commitment laws were summarized nicely in this law review article.

Sex offender commitment laws are a failure. They are expensive and ineffective. They consume resources intended for those with serious psychotic illnesses. As states trend away from commitment policies they will likely continue to pursue other options such as enhanced criminal sentences, sex offender registries, mandatory reporting laws and extended home monitoring programs. If sex offender legislation is coming to your region, be aware of these issues.

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By the way, I'm rather disappointed in Time magazine for picking a short grey-haired nun-type nobody as Person of the Year. What were they thinking?

Sheila Matthews, from AbleChild.org, suggested requiring MedWatch info on all pharmaceutical advertising. I think this is a great idea. MedWatch is the voluntary, side-effect reporting mechanism for the FDA. Few prescribers and fewer consumers use it to report side effects. They should go one further and make it very easy to report side effects... almost as easy as googling the side effects.

There were two out of state attorneys who brought a number of their clients to testify. There were also at least two people there testifying for the Church of Scient ology's C C H R (and making excellent points, I might add, about Lilly's reported lack of following through with their promise 15 years ago to provide additional data. There were quite a few who lost family members tragically after taking only several doses of medication. It is indeed hard to understand how a chemical can cause one to conduct such complex, planned behaviors. Yet, listening to their testimony, it was hard to wonder how their response to these antidepressants could not have contributed to their deaths.

Heidi Bryan, from the Feeling Blue Suicide Prevention Council, pointed out that a big part of the not-enough-follow-up problem was due to the lack of parity for mental health treatment. Even Medicare charges 2-1/2 times as much for co-payments for outpatient mental health diagnoses than they do for the same symptoms caused by non-psychiatric diagnoses (e.g., major depression vs hypothyroidism).

I think that managed care and pharma has so convinced folks that taking a pill is just as effective as talk therapy, that there is now a backlash that will soon require these companies to drop their discriminatory policies.

All of the voting committee members, including Wayne Goodman, Gail Griffith, George Armenteros, Andrew C. Leon, Marcia J. Slattery, Susan K. Schultz, Jean Bronstein, and the chair, Daniel S. Pine, repeatedly pointed out the importance of balancing any labeling changes with language which emphasizes the need to weigh the relative risks of nontreatment with those of treatment, even comparing the risk of treatment with that of non-treatment. In fact, when the vote came up about extending the language in the black box to include the young adults, two members voted against (Griffith and Pines), while the other six voted for it under the condition that balancing language be included as well. They told the FDA that they wanted to review the draft language prior to making a final decision.

Joe Glenmullen, who authored "Prozac Backlash", testified, as well. He and others state the the FDA has been tricked by the drug companies, by not being given complete information about all clinical trial results.

So, then the committee deliberated for a few hours. I must say, the committee members rather awkwardly, but repeatedly, made several important points...

The FDA needs to make the drug companies collect and provide better data.

There is inadequate data on this "activation syndrome", referring to akathisia, agitation, and anxiety apparently induced by antidepressants in some individuals.

Collecting pharmacogenetic data might help in determining which individuals might be at higher risk of developing this and other side effects.

The FDA is not collecting adequate data to differentiate between suicidal thoughts and suicidal behaviors and attempts. The pharmaceutical companies need to be directed to supply this type of fine-grained data. The fact that the currently reviewed data on "suicidality" makes it impossible to differentiate these two important characteristics suggests that any change in warning language needs to be carefully worded.

The committee insisted on the FDA adding balancing language to reflect not only the increased risk of "suicidality" in young adults, but also the other side of the coin -- the increased risk associated with untreated depression. Additionally, they'd like language which refers to the apparent protective effect of these drugs in older adults, especially in seniors. It was noted that this would be the first time that the FDA has included in a black box information of a positive nature.

They are concerned about the unintended consequences of decreased access to depression treatment as a result of the black box warning. Recent CDC information was noted, indicating that since the 2004 pediatric black box was added, prescriptions in kids are down, while suicides are up. This trend has already been noted in adults, and the fear is that it will only get worse with language that extends to young adults.

The "25 to 30 year old" group mentioned in Part 1 was not chosen scientifically. It just fit the data. Thus, there is nothing special that happens when you turn 25 or when you turn 31to alter your risk. Because of this, they considered instead using language like "young adults", but this idea didn't seem to be too popular.

Some of the possible explanations discussed for the biphasic nature of the data (higher risk when younger, lower risk when older) included induction of mania, late maturation of frontal lobes so impulsivity and experience improve as you get older, and greater tolerance for uncomfortable affect with age. They agreed that more data would be helpful.

The committee also felt it was very important to emphasize the need for close follow-up when treating people of any age with depression. There was concern that it could sound like older people don't need to be followed as closely due to this "protective effect".

Finally, the FDA acknowledged concern about telling doctors how to practice, and crossing the line into federal regulation of the practice of medicine. However, it was pointed out that, when the stakes are high enough, as with clozapine, the FDA has had no trouble advising things like frequency of monitoring lab tests. Telling prescribers that people with depression starting antidepressants should be followed at least weekly at first should be no different. Hopefully, they won't wimp out.

I'll leave you with two good quotes.

"Maybe we don't need a black box on antidepressants. Maybe we need a black box on Depression."

Friday, December 15, 2006

I have been unanimously elected in an uncontested democratic process to write a response to the Christmas meme that Carrie generously tagged us with.

1. Hot Chocolate or Egg Nog? Hot chocolate! Like there was ever any question. The four basic food groups are: chocolate, caffeine, salt and cholesterol. I'm a doctor, I should know.

2. Does Santa wrap presents or just sit them under the tree? The only unwrapped things under my tree were my cats. Occasionally they wore wrap too. And bows. What good is a holiday if you can't humiliate the pets?

3. Colored lights on tree/house or white? Colored, but only when they weren't burned out. And generally only on the top half of the tree or the cats would get them. Yes, the tree looked funny.

4. Do you hang mistletoe? Absolutely not!!! I use lethal injection.

5. When do you put your decorations up? Whenever the cats knocked them down. Several times a day.

6. What is your favorite holiday dish? Not lutefisk. To understand this, read a description of one person's first experience with lutefisk. I'll borrow my favorite quote to save you some time:

"Lutefisk is instead pretty much what you'd expect of jellied cod; it is a foul and odiferous goo, whose gelatinous texture and rancid oily taste are locked in spirited competition to see which can be the more responsible for rendering the whole completely inedble."

7. Favorite Holiday memory? Rushing home from the church Christmas pageant with a bag of treats (green and red popcorn balls) and getting home just in time to see the Peanuts Christmas special. (Would it be tacky to ask an accomplished pianist like Carrie to put up an audio clip of that great Peanuts dance song?)

8. When and how did you learn the truth about Santa? When I noticed that Santa wrote with the same illegible scrawl as my Dad. In addition to being an accomplished Santa forger, he is also a serial killer of squirrels. And they wonder why I became a forensic psychiatrist.

9. Do you open a gift on Christmas Eve? Absolutely. Especially any gifts that tick, smell or dribble.

10. How do you decorate your Christmas Tree? Um..from the top down?

11. Snow! Love it or Dread it? Like it makes a difference?! IT WILL SNOW ANYWAY, DEAL WITH IT. I hear Finns have 40 words for snow----all of them obscene.

12. Can you ice skate? I can, but I prefer to entertain everyone by purposely sliding around on my butt.

13. Do you remember your favorite gift? A cemetary plot. True story: My parents finished their estate planning and realized they had an extra burial plot. They gave it to me for Christmas, with a nice card that had the directions & cemetary location. To this day I keep it in a drawer with my Christmas card list and other bright cheery things. It's perversely funny in a Tim Burton sort of way.

14. What's the most important thing? It's only one day a year, and then the world will go back to normal.

15. What is your favorite Holiday Dessert? See question number 1.

16. What is your favorite holiday tradition? Putting bows on the cat.

17. What tops your tree? I'm too short to reach the top. Like I said, the tree looks funny.

18. Which do you prefer giving or Receiving? Like we say in the corrections business, it's better to give than to receive. Especially certain inmates.

19. What is your favorite Christmas Song? That Peanuts Christmas special dance song that I want Carrie to post on her blog. It's the least she can do after tagging us!

Thursday, December 14, 2006

I attended yesterday's hearing, missing the FDA's presentation in the morning, but arriving for the public comments part and the afternoon deliberations. (Check out the FDA's 150-page .pdf testimony.) I was also among the 75 people who provided testimony to the committee. The meeting lasted a total of 9.5 hours!

This is the first time I've been to an FDA Advisory Committee meeting. These are public meetings (required to be public, by law) in which the committee members discuss the issues and make decisions. The FDA presents data to them; in this case, it was data from numerous clinical trials solicited from big pharma to especially get at the question of induction of suicidal thoughts or behaviors by antidepressant medications. After the committee hears these data, they listen to public testimony. After that, they discuss what they heard, and respond to the FDA's recommendations in the form of support, opposition, or other recommendations.

The committee is advisory in nature, meaning that the FDA takes what they say into consideration, but is not bound by their recommendations. The FDA does typically follow their recommendations. Three of the committee members could not vote due to conflicts of interest (receiving industry funds for clinical research and such).

In this post, I will first cut to the chase and tell you what the committee's recommendations were. In a second post, I'll give you more details to flesh out some of the discussion points and concerns that the committee raised, and also discuss the public testimony, some of it being very gut-wrenching and impassioned.

If I had to choose one image that best describes the entire hearing, it is the one above.

What this demonstrates is that as age goes up, the relative risk of suicidal thoughts or behavior goes down. The numbers plotted are the Odds Ratios... meaning that, compared to the folks taking placebo, what are the odds that those taking antidepressants are likely to have either thoughts of suicide or actual suicidal behavior. So, an O.R.=1 means that the chances are the same, which means no difference. An O.R.=2 means your chance is doubled. An O.R.=0.5 means your chance is halved. The black square is the estimated O.R., and the gray bar represents the 95% Confidence Interval... meaning that the statistical probability of the true O.R. being within the gray bar is 95%. Thus, if the gray bar touches 1 (the vertical dashed line), then the two groups (placebo and medication) are NOT statistically significant. If they do not touch 1, then they ARE statistically significant. Got it? To put it most simply, left of the dashed line is good, right of the line is bad.

So, the pediatric Odds Ratio does not include 1; this result supports the decision made in 2004 to add a black box warning that says these medications are associated with an increase in suicidal thoughts or behavior. (As it turns out, it is just thoughts, not behavior, but I'll address that in the second post.)

The 18-24 year-old Odds Ratio does include 1 (0.91-2.70), thus we cannot say that there is an increased risk.

The 31-64 year-old Odds Ratio just includes 1, but the estimated O.R. is less than 1, meaning that we cannot say there is a decreased risk, but there almost is.

For the over 65 group, there is clearly a significantly decreased risk of suicidal thoughts or behaviors. Note that these appear to be rare events... 12 people out of 3227 taking medication, and 24 out of 2397 taking placebo reported suicidal thoughts or behaviors. Hard to believe that only 1% of people with major depression had suicidal thoughts, huh?

Okay, so here is what the committee decided:

There is a clear relationship between age and suicidal thoughts or behaviors in people taking antidepressants.

Keep the black box warning that currently exists, but be very cautious about discouraging depression treatment and attempt to include balancing language that states that the risk of suicidal thoughts or behaviors when not taking medications should be considered. (They do not have data that tells them what that number is.)

Encourage careful monitoring of all people being treated for depression.

Extend language in the black box to indicate that the increased risk of suicidal thoughts or behaviors extends to around age 25, where it starts to drop off and become a decreased risk in the 30's and up.

Encourage collection of data on the "activation syndrome" that some people get when taking antidepressant medications, especially SSRI's.

Encourage collection of data which differentiates between suicidal thoughts and suicidal behaviors.

So Fat Doctor posted about writing her holiday cards. I feel like she's my friend....it's the strangest thing, but I track this person's life. I know when her sister had bladder surgery, when she painted her toenails blue, and how did she lose 8 pounds in one week??? I wonder what state she lives in (not to mention how she works on the same medical unit as her mother). Son, husband, sister, big dog, little dog, it's like Reality Blogger.

Holiday Cards: growing up, my family never sent them. I grew up (I think) and started sending them, including pics after we had kids. I learned to paste in photos, and while I'm not much for newsy letters, I've moved from "our year in review in pictures" to a few travel photos and a sentence about each family member. Some years it's simply "the kids have too many activities to list." Mostly, I keep it short and sweet, and I don't mention the more troublesome aspects of life: there are always a few. If you know me, you hear them, if our relationship is sustained only by the yearly holiday card, I leave out the bad stuff. On the receiving end, we've gotten some really interesting ones. Last year was the first time we learned someone's ejection fraction from their holiday newsletter. One friend sent a month-by-month, 2 page, single-spaced account of every kiddy performance and academic conference.

Fat Doctor and I exchanged e-cards off blog (-- I think this is called "back door"). She has a name (only a first name)! I was shocked, I've wondered what state she lives in, how fat she really is, and my husband has wondered if she really exists, but it never occurred to me that she'd have any name but "Fat Doctor" or FD. It was like a bubble bursting, and while it's a nice name, it was a little bit disappointing, like seeing your favorite glamorous movie star without their makeup. The newsletter itself was full-form Fat Doctor, I loved it. Gorgeous, gorgeous little boy -- he's made brief appearances on the blog, so an old familiar face-- and much of the news I knew. Up there with writing about one's ejection fraction, Fat Doctor sends advance directives for both herself and Husband. He wants his life sustained as long as he can operate the TV remote. This reminds me of Roy, who once said he wanted to be kept alive as long as he could move a cursor by any means. I wonder if Roy puts that in his holiday notes? For the record, and this did not make my holiday card: If I am unable to consent, I am never to be put on a salt-free, diabetic diet. I mean that.

Are you asking, what's this got to do with Psychiatry?? We didn't get very many comments on our anti-depressants and suicide posts, timely stuff that it is; I figured I'd digress to pleasanter topics for a few moments. Maybe Roy will fill us in on the FDA hearings.

Wednesday, December 13, 2006

Dinah mentioned the recent Finnish study, showing an associated protective effect of antidepressants on death and on completed suicides, but an associated increase in the number of suicide attempts. I thought I'd share, for teaching purposes (and thus subject to Fair Use), the data in the article on individual medications.

For those unskilled in looking at Relative Risks, an RR of 1.0 indicates no higher or lower risk of the outcome being measured (compared with the comparitive population... in this case, suicide survivors not on meds). An RR or 0.5 would indicate a risk that is half of expected, and an RR of, say 2.0, indicates a doubling of the risk. (Note that this is intended for a professional audience... these data should not be applied to one's own personal situation and you should discuss it with your physician if you have any questions.)

Risk of Suicide

Figure 1. Relative risk and 95% confidence interval of suicides obtained by using medication as a time-dependent variable. The relative risks were adjusted with the propensity score method, and by including sex, age, geographical location (as strata), number of suicide attempts before the index hospitalization, number of suicide attempts during follow-up, use of multiple antidepressant medications, and number of purchased antidepressant prescriptions during the previous year in the model. SNA indicates serotonergic-noradrenergic antidepressant; SSRI, selective serotonin reuptake inhibitor; and TCA, tricyclic antidepressant. Citalopram was given as citalopram hydrobromide; doxepin, as doxepin hydrochloride; fluvoxamine, as fluvoxamine maleate; mianserin, as mianserin hydrochloride; paroxetine, as paroxetine hydrochloride; and venlafaxine, as venlafaxine hydrochloride. From: Tiihonen: Arch Gen Psychiatry, Volume 63(12).December 2006.1358–1367

You can see that the only two drugs which do not touch the vertical line representing an RR=1 are fluoxetine (Prozac) and venlafaxine (Effexor). These suggest that fluoxetine use has a significantly lower associated risk of suicide, while venlafaxine has a significantly higher associated risk of suicide.

Risk of Suicide Attempts

Figure 2. Relative risk and 95% confidence interval of suicide attempts obtained by using medication as a time-dependent variable. The relative risks were adjusted as explained in the legend to Figure 1. Abbreviations and complete drug names are also given in the legend to Figure 1.From: Tiihonen: Arch Gen Psychiatry, Volume 63(12).December 2006.1358–1367

This one shows that anyone put on meds was more likely to have attempts (keep in mind these pts were not randomized, so it may be that those who were not placed on meds had a lower risk of future attempts).

Risk of Death

Figure 4. Relative risk and 95% confidence interval of total mortality obtained by using medication as a time-dependent variable. The relative risks were adjusted as explained in the legend to Figure 1. Abbreviations and complete drug names are also given in the legend to Figure 1.

This one shows that there was clearly a reduction in the relative risk of death for pts on fluoxetine, citalopram (Celexa), sertraline (Zoloft), mianserin (not in US), mirtazapine (Remeron), and "other antidepressants". None were associated with an increased risk of death.

The authors suggest that the antidepressants, especially SSRIs, may have a protective cardiovascular effect, possibly due to their mild blood-thinning effect.

Tuesday, December 12, 2006

The Medical Blog Network took a survey in the past few months on the "healthcare blogosphere", asking bloggers why they do that thing that they do. The results are available as a pdf. (Note that the surveyor, Envision Solutions, cautions that the results are not scientific (wasn't randomized) and should not be generalized all healthcare bloggers.)

about 200 healthcare bloggers (>30% of posts are health-related) participated

3/4 were from US

about evenly split by gender

21% were physicians, 7% patients, 5% nurses

majority are age 30-50

Some notable figures:

39% blog anonymously

about half spend 1-2 hours/day on it

one-fourth accept advertising, while half are willing to do so

the group was split on how ads may affect perceived credibility, though most feel the credibility of the particular blogger outweighs any potential negative impact from ads

Monday, December 11, 2006

Great title, eh? I started out with "My Favorite Delusions" but I just had to change it based on a case I heard about today. Face it, one of the reasons we go into psychiatry is because our patients can be fascinating. Or more specifically, their delusions can be fascinating. At times it can be tough to sort out non-bizarre delusions from reality, but the truly bizarre ones can be very complex and interesting.

In prison the most common isolated delusion I see is the contamination delusion. An inmate will believe that people are putting something into his food. He will go into great detail to point out something about the food that doesn't look or smell right, or will have some type of somatic symptom that he believes is proof that something has been done to him. In addition to giving medication, you can temporarily relieve anxiety by giving the inmate only food in unopened packages and this can help while you're waiting for the medication to kick in.

Being close to our nation's capitol we also sometimes get folks with politician-related delusions. They get arrested while travelling to Washington to confront the "devil-worshippers" controlling the government, or to get in touch with their "relatives" who happen to live in the White House. (Bush and Clinton would be surprised to learn how many patients they've fathered.) Presidential threateners are rare, but do show up occasionally. I understand the Secret Service even has a team that functions as something of an assertive community outreach program to ensure that threateners get their medications in the community.

But in addition to that, I've got a few other favorites:

Olfactory reference syndrome

This is the belief that one has a foul body odor. It's not a true hallucination in the sense that it is a smell that is associated with an idea, rather than just a perception. People will associate the smell with a body part which can lead them to excessive or repetitive washing or bathing. People with this delusion sometimes feel compelled to isolate themselves from others or to repeatedly apologize to others for their smell.

Capras syndrome

Also called imposter's syndrome, it's the belief that familiar acquaintances have been replaced by imposters. Think "Invasion of the Body Snatchers".

Fregoli syndrome

This is the inverse of the Capgras delusion. With Fregoli syndrome people believe they are being followed or stalked by someone who changes shape or form to look like others. If any of you have seen the Denzel Washington movie "Fallen" you can get an idea of what Fregoli syndrome would be like.

Koro

This is the belief that one's penis is disappearing or shrinking into one's body. This is not to be confused with kuru, a degenerative neurological disease caused by prions transmitted by cannibalism.

So what got me on this delusional theme today? I heard about a case of someone who believed he was having sex with fish. I will never look at the Little Mermaid in quite the same way again. I can only hope he's practicing safe sushi.

Do SSRI's cause people to become suicidal? The question feels old-- I remember when these medications first came out and there were questions about whether the medications made people violent, seems that years later we still have the same questions.

It seems like this is something we should know-- it's been a while now, two decades in fact. It's easy if everyone who takes a medication gets an unusual symptom, harder if only a few people who take a medication have an adverse reaction, and harder still if the symptom caused by the medication is the same as the symptom caused by the disease the medicine treats!

In 2004, the FDA mandated that all the newer anti-depressants carry a black box warning stating that they may cause suicidal ideation in children and adolescents. The research is convincing that a small percentage of children (1 to 2 percent) who were not having ideas about suicide before they started medications, had them after they started, generally in the first weeks of treatment. No child in any study died of suicide, though this is such a rare event that it gets difficult to look at prospectively. Sorry, no links here, I've just heard a bunch of talks. Most recently (meaning last week) I heard Mark Riddle, the Chairman of Child Psychiatry at Johns Hopkins Hospital talk about treating adolescent suicide attempters: he noted that in any given year, 2.9 percent of adolescents have a suicide attempt requiring medical treatment. Think about this, it's a general population number: in a high school of 1000 kids, 29 will have a suicide attempt requiring medical intervention, many more will have suicide gestures and not get help. Completed suicides? 6 to 8 per 100,000 .... a rare event, but given that kiddy death is pretty rare, a significant cause of childhood mortality.

This coming week, the FDA will hear testimony about whether the Black Box warning should also include adults. See: http://www.fda.gov/ohrms/dockets/ac/06/briefing/2006-4272b1-index.htm and press the link for the brief if you'd like to read all 140 pages in a pdf file. What will a Black Box warning mean? In my psychiatric practice, I don't think it will mean anything. Many of my patients feel helped by these medications. It may make some patients with depression less willing to try medicines, and more importantly, it may make some primary care docs afraid to prescribe them. I have to wonder why some symptoms get the dreaded Black Box warning and other's don't and why the designation has become so heated. Another post for another day.

So last week, the Archive of General Psychiatry published this amazing study on a followup of over 15,000 patients in Finland. It included all patients admitted to Finnish hospitals for suicide attempts over a 7 year period (excluding those with psychosis) and followed their future behaviors noting whether or not they took medications and which medications they took. I tried to follow the charts and the data, but it was too confusing and too overwhelming. Please, if anyone out there could follow these statistics, please help me. I was left to just read the results and the conclusions and some of the thinking about it all. This study, however, is terrific in that in includes everyone in the country who attempted suicide, and they tracked whether the patients filled their prescriptions, so they had a fairly good idea of whether the patients were actually taking them.

And the findings? People taking SSRI's/SNRI's (eg effexor) had a markedly higher rate of serious suicide attempts. Now this could be because the people given/ or taking the medications were sicker-- there's not necessarily a cause and effect here. Furthermore people taking SSRI's/SNRI's had a markedly lower rate of both completed suicide and death from cardiovascular disease (Hey, didn't Roy talk about this on our podcast???). Some of the numbers surprised me: in their avg 3.4 year follow up of 15,390 , there were 1583 deaths-- could it be that nearly 10% of their suicidal patients died? 602 were suicides. The average age of their population was just under 39. The protective factor for cardiovascular mortality was huge: 30-40% reduction in deaths.

Other interesting facts: Paroxetine (paxil) was associated with a high mortality among the 10-19 age group with 4 deaths: 1 suicide, 1 drowning, 2 unintentional injuries. Venlafaxine was the only medicine associated with increased risk of suicide and Fluoxetine (prozac) was the only one associated with decreased risk of suicide. And I didn't see bupropion (wellbutrin) mentioned anywhere at all in the article. The strongest predictor of completed suicide was number of past attempts.

Sunday, December 10, 2006

We'd like to thank our readers and listeners for your kind comments and suggestions about our first podcast. This one's a bit longer, at about 33 minutes. I think we'll get better about the time. About 20 minutes seems to be a good balance.

This is actually the second half of the original podcast, which went long so we sliced it into two podcasts. Don't expect to get a podcast every other day... if we do one every other week, I'll be pleasantly surprised (though I'm striving for every Sunday). Maybe we can be like Digg's Kevin Rose and Alex Albrecht and drink alcohol at the beginning of each podcast... that would be interesting.
Here are the show notes for the podcast:

December 10, 2006: Roots

Topics include:

Dr Anonymous is again not mentioned in this podcast (but we do thank him for the idea about the musical bumpers between topics)

FDA hearing on December 13 about adding a black boxed warning on antidepressant labels about the possibility of increased suicidality in adults: Will this reduce access to these drugs, causing undertreatment of depression and actually INCREASE suicide rates? (Check here for background materials)

"Emotionally, however, I feel as if severing a link to an RSS feed is tantamount to entirely giving up on a blog; with so many other potential distractions out there, the chances of me returning in a timely manner are miniscule... I need a better option. Or… can everyone just stop posting for a while until I can read everything you’ve written so far?"

Cool MicroMemo device attaches to your Nano to become pocket recording studio. Now I can podcast from anywhere (jk).

Washington Post reports that the V.A. is underfunding mental health services. Are we surprised? All of health care is getting hit these days, but people with psychiatric illness tend to get hit harder.

Another Post article relating to our recent discussion about PTSD medications. The drug, guanfacine, which works in a somewhat similar manner to propranolol, has been shown to be ineffective for PTSD. Newsflash: who uses guanfacine for PTSD? I have never seen a patient on it.

Yet another teen with mental illness, stuck in limbo between the mental health and the forensic system. As in the previously mentioned case, it is extremely challenging to get these folks the help they need in the right setting.

Last chance before 2053 to see Jupiter, Mercury & Mars, all lined up in a bunch. Okay, you have to get up an hour before sunrise to catch it, low in the southeast sky. For me, that just might be worth getting up for. For Son, "it'll look just like all the other little white dots that you've dragged me out of bed to "wonder" at. Knock yourself out, Dad."

posted by dinahI tell people things about my life and they look at me kind of funny. It's that look that says, really loudly despite the fact that no noise pops out, "You do what?" or maybe more like, "You do What? Clink did it recently when I mentioned that I have coffee every morning with my friend the judge and her dog, Tex. She said, "Every day? How do you do that?" Just to be clear on this, I have coffee every morning with a friend (sometimes two), for twenty-five minutes, right before work, it's how I start my day, every day, for years now.

Oh, and I write fiction-- one more way to get funny looks. Now I take a grad school course in fiction techniques (doctors aren't suppose to do this). Did I mention I have a psychiatry blog? At that point, the noise gets louder, I'm told I have much too much free time. And should I bother with the fact that I exchange emails three times a day (yes, I mean three times a day, well sometimes more) with a high school friend I reconnected with after decades? And that we've done this every day for the last 18 months or so?

I used to feel a bit awkward about it. I've wondered why other people don't have more time (they're quick to point out to me that it's because I work part-time, what can I say?). For a while, my answer to "how do you have time?" was to get a bit defensive and say "I'm more efficient than you." (--amazing anyone even wants to be my friend, but hey...ask an obnoxious question and...).

I've given up, I concede, and now I just say, "I have the life everyone else wants."

Friday, December 08, 2006

I'll get in on this bloggle (bloggle:blog::gaggle:goose) about legislating common sense.

In Maryland's last legislative session, a well-meaning senator introduced Senate Bill 329, which provides for mandatory obesity screening for every child in the 1st, 3rd, 5th, and 8th grades. The child's Body-Mass Index (BMI) would be measured, and a "health report card" would be sent home to the parents, informing them of the results.

Imagine that, getting a letter from school informing you that your son is fat. I can imagine the conversation now at the dinner table.

Thursday, December 07, 2006

My title is a take-off on ClinkShrink's title. I was thinking of commenting on her post, and decided I wanted one of my own.

So Clink talks about the idea of legislation as it effects how health care is delivered. We've already talked about the NHS Blog post on proposed legislation in the UK to mandate psychiatric evaluation (or screening?) of all those entering hospice care. Clink goes on to talk about legislation mandating screening for post-partum depression in New Jersey, and her feelings about legislating health care relationships. See Mandatorily Yours below.

I think the whole world is nuts.

Okay, let me explain. Basically, I believe you live until you die, and that there are only a handful of things that one can control. The biggest, obvious causes of unnecessary premature preventable death are obvious: Smoking and Car Accidents seem to cause a lot of preventable mortality. People, however, want autonomy, and want to make their own choices: no matter how you dice it, smokers want the choice to kill themselves. And while I don't smoke, I do drive, and while I don't drive drunk and I'm reasonably careful, even good, careful, law-abiding drivers are susceptible to death. Last I checked, it's illegal to drive while intoxicated, but this mostly seems to be an unenforceable law.

So what can we control, and should we? What do we, as a society, choose to legislate, and does it make sense? Over forty years after the Surgeon General's warning about the dangers of smoking, we're finally making it illegal in public places. You may be legal to drive after a drink or two, but if you're on your death bike (oops, I meant motorcycle), you may be required to stick a helmet on your head --so much for the wind ruffling through that gel-held hair-- and to buckle your seat belt. Should we go further? Why should you be allowed to stroke out - should we mandate yearly blood pressure screening? Should we make junk food illegal? Please say no! But wait, in New York City, they've passed a law banning trans fats in restaurants ! So you can smoke then have a couple of drinks (keep that level under 0.8) and jump in your car (don't forget to buckle up), but I can't eat a donut?

Wednesday, December 06, 2006

The Associated Press today reported a story about a recent JAMA article on the mental health problems of new mothers in the post-partum period. This study was a 30 year followup of over two million Danish women. It found that one out of every 1,000 women develop a mental disorder of some type after giving birth. For first-time mothers the highest risk period was in the first three months after birth. Clinical depression was the most common diagnosis seen, followed by bipolar disorder and schizophrenia.

Given our recent blog thread about mandatory screening for hospice patients, I was not surprised that some versions of this story included a suggestion to mandate mental health screening for pregnant women. Mandated screening for disease is nothing new. Many states have laws requiring hospitals to screen newborns for genetic metabolic diseases. Schools are required to screen children for vision and hearing problems. Certain occupations require mental health or medical screening as part of the job application process. Correctional facilities are required to screen all new intakes for physical and mental illness.

Given that this is common, what's one more law requiring another screen? New Jersey's mental health screening law looks pretty reasonable. It's intended to provide education about depression to the new mother and the family. It offers referral information and other resources. It doesn't require the participation of scarce psychiatrists.

It's hard for me to put my finger on exactly why laws like this get to me. The most obvious question is, since this is such an obvious good idea why do we need to make a law about it? The Surgeon General's office doesn't require legislation whenever they start a public education campaign about the disease du jour. The CDC doesn't require legislation to put out medical alerts about breaking issues. It just seems like a bit of overkill.

The second somewhat more cynical concern is that mandated screening is also sometimes linked to mandatory reporting. This is seen more often in the realm of infectious disease where infected patients are reported to the local health department for contact tracing. I remember though in the early days of the AIDS epidemic that patient registries were linked with proposed policies for things like mandatory quarantines. Once identifying information is mandatorily collected (and in corrections I associate this with DNA collection) it cannot be withdrawn. And the future doesn't always guarantee this information will be used beneficially.

The third and final reason I object to this kind of legislation is that it really interferes with patient autonomy and the right of physicians to decide when and where to bring up delicate medical issues with their patients. What if the mandated screening is for a disease with no known cure? Would I be required to find out my fate even if I didn't want to know it?

Perhaps I am being a bit too dramatic, but over the years I've learned that you can never be too cynical when it comes to legislative involvement in health care. I'm sure some parents occasionally wish they had chosen cats over children or may think they must have been crazy to have kids, but I don't think we need to have Congress tell them so.